Pathophysiology and Management of Chest Wall Pain after Surgical and Non-Surgical Local Therapies for Lung Cancer

Chest wall pain syndromes can emerge following local therapies for lung cancer and can adversely affect patients’ quality-of-life. This can occur after lung surgery, radiation therapy, or percutaneous image-guided thermal ablation. This review describes the multifactorial pathophysiology of chest wall pain syndromes that develop following surgical and non-surgical local therapies for lung cancer and summarizes evidence-based management strategies for inflammatory, neuropathic, myofascial, and osseous pain. It discusses a step-wise approach to treating chest wall pain that begins with non-opioid oral analgesics and includes additional pharmacologic treatments as clinically indicated, such as anticonvulsants, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, and various topical treatments. For myofascial pain, physical medicine techniques, such as acupuncture, trigger point injections, deep tissue massage, and intercostal myofascial release can also offer pain relief. For severe or refractory cases, opioid analgesics, intercostal nerve blocks, or intercostal nerve ablations may be indicated. Fortunately, palliation of treatment-related chest wall pain syndromes can be managed by most clinical providers, regardless of the type of local therapy utilized for a patient’s lung cancer treatment. In cases where a patient’s pain fails to respond to initial medical management, clinicians can consider referring to a pain specialist who can tailor a more specific pharmacologic approach or perform a procedural intervention to relieve pain.


Introduction
Lung cancer remains the leading cause of cancer death. 1 With increased early-detection screening efforts, more diagnosed lung cancers are early-stage and therefore amenable to local therapies, including surgery, radiation therapy, and percutaneous image-guided thermal ablation (IGTA). 2 With appropriate therapy for earlystage lung cancer, 10-year survival rates can exceed 70%. 3 Yet, these local therapies can be associated with treatment-related chest wall pain that can adversely impact patients' quality-of-life for extended periods of time.
The etiology of chest wall pain is associated with the type of local therapy delivered.For example, chest wall pain that occurs following surgery is generally due to trauma from the incision and surgical manipulation of the chest wall. 4It occurs following radiation therapy due to ischemic, necrotic, and fibrotic changes in the irradiated tissue. 5It occurs following IGTA due to trauma of the surrounding tissue from needle insertion, heating, or freezing. 6hile the iatrogenic mechanisms leading to chest wall pain after surgery, radiation therapy, or IGTA may be unique, there are shared pathophysiological components including inflammatory, neuropathic, myofascial, and osseous injuries as described below. 7nflammatory pain occurs due to the immune system's response to acute tissue damage, leading to the release of cytokines, chemokines, and prostaglandins that act as pain mediators. 8This causes inflammatory hyperalgesia, where nerve terminals near the injured tissue become over sensitized.This type of pain persists until inflammation resolves and responds well to antiinflammatory medication. 9europathic pain arises from peripheral nerve damage, resulting in heightened neuronal activity and central sensitization.This alteration in pain processing causes persistent hyperalgesia (heightened sensitivity to painful stimuli) and allodynia (pathological sensitivity to stimuli that are not normally painful). 9europathic pain can be differentiated from inflammatory pain by the presence of allodynia, by its persistent effects beyond the resolution of inflammation, by the poor response to anti-inflammatory medication, or by the presence of negative symptoms, including sensory or motor loss. 9,10yofascial pain develops due to trauma inflicted on muscle fibers, leading to ischemia.This disrupts the function of intracellular calcium pumps, resulting in increased levels of intracellular calcium.Consequently, this triggers persistent muscle contractions, stiffness and tenderness of the chest wall, and formation of myofascial trigger points. 11Local stimulation of trigger points reproducing a patient's pain is pathognomonic for myofascial pain.
Lastly, osseous pain occurs due to rib fractures in the treated chest wall during surgery or following radiation therapy or IGTA. 6,12,13This can be diagnosed via computed tomography (CT) scans, though fractures are not always immediately visible.
Due to its multifactorial nature, management of chest wall pain syndrome is complex and often benefits from a multimodal approach.This review intends to better elucidate the pathophysiology of chest wall pain syndromes that arise post-lung cancer treatment and summarize evidence-based approaches for their management.These strategies include non-opioid oral analgesics, neuropathic pain medications, topical treatments, opioid analgesics, physical medicine techniques, and procedural interventions.

Thoracotomy
Traditional lung resections involve an approximately six-to nine-inch posterolateral thoracotomy incision, typically between the fifth and sixth ribs.Depending on the location of the tumor and the specific surgical technique, the muscles overlying the chest wall are dissected and the ribs may be retracted to allow for better access to the lungs.During this process, traumatic injuries occur to the costochondral and costovertebral joints, ribs, muscles, pleural lining, and intercostal nerves (Table 1). 4 This can lead to inflammatory pain until wound healing resolves, neuropathic pain due to transection of the intercostal and pleural nerves, myofascial injury and trigger point formation due to injury of the chest wall muscles, and rib fractures due to intraoperative retraction of the ribs.
Following a thoracotomy, approximately 30% to 40% of patients report pain beyond three months with 5% to 10% reporting a score greater than 5 on a 10-point scale. 10This can lead to prolonged opioid use beyond 90 days post-operatively in approximately one in four patients. 14Factors such as how the ribs were manipulated, how retraction was performed, whether muscles were split, and the number of inserted chest tubes affect the risk, severity, and duration of chest wall pain. 15

Minimally Invasive Surgery
In contrast to thoracotomy, video-assisted thorascopic surgery (VATS) is a minimally invasive surgical technique that uses small incisions to insert a surgical camera and thorascopic tools into the thorax.At least one incision site must be expanded to allow for removal of the resected lung tissue, which carries the highest risk of intercostal nerve injury. 168][19][20] A 2016 Danish study by Bendixen et al. 17 that randomized 206 patients between anterolateral thoracotomy and VATS found that in the first year following surgery, VATS led to significantly lower post-operative moderate-to-severe pain (defined as 3 on a 10-point scale, p < 0.0001) and significantly higher patient-reported quality-of-life (p ¼ 0.014).In that report, 9% of patients experienced moderate-to-severe chest wall pain one year after VATS versus 14% after thoracotomy, suggesting that chest wall pain can still occur despite the less invasive approach.

Conventionally Fractionated Radiation Therapy
Conventionally fractionated radiation therapy (CFRT) is delivered to patients with locally advanced NSCLC with low doses of daily radiation (1.8-2.0Gy/ fraction) given over approximately six weeks with the goal of causing lethal DNA damage within tumor cells.It is often delivered concurrently with chemotherapy, which increases the likelihood of both tumor death and adjacent normal tissue injury.CFRT is an uncommon cause for chest wall pain, although it can occur with symptoms like those following surgery, with patients reporting pain, paresthesias, or hypoesthesias. 21The onset of symptoms is delayed, with most patients reporting the emergence of symptoms 10 to 22 months after CFRT. 22he pathophysiology of radiation-induced chest wall pain is multifactorial.It is believed to be caused by recruitment of inflammatory cells to the irradiated tissue following oxidative damage (Table 1). 23It is also believed to be a consequence of normal tissue atrophy and chronic ischemia contributing to peripheral nerve injury. 22Autopsy findings have shown marked fibrosis of the nerve sheaths with demyelination and atrophy within irradiated tissues. 22Fibrosis often results from chronic ischemia and can compress peripheral nerves. 5hest wall pain may also be related to delayed rib fractures that can be invisible on chest X-ray and CT.This occurs due to injury of the Haversion canals, leading to reduced blood flow and sclerosis of the bone marrow, decreased osteoblasts, and decreased collagen production. 12Finally, radiation therapy can rarely cause myonecrosis of the pectoralis muscles, leading to myofascial pain. 24

Stereotactic Body Radiation Therapy
Stereotactic body radiation therapy (SBRT) delivers large doses of radiation to lung tumors in five fractions or less to improve the likelihood of local control versus CFRT. 25,26This is associated with higher rates of chest wall pain, with up to 18% of patients reporting chest wall pain after treatment. 27,28It occurs at a median of 7.1 months after SBRT and lasts for a median duration of 4.7 months. 5There is an association between chest wall pain syndrome after SBRT and short tumor-to-chest wall distance. 29The highest risk area is the posterolateral chest. 30

IGTA
Another non-surgical treatment for lung tumors is IGTA.In this procedure, a probe is inserted percutaneously through the intercostal space into the lung tumor under CT guidance to deliver radiofrequency ablation (RFA), microwave ablation (MWA), or cryoablation.This causes immediate tumor cell necrosis inside the ablation zone. 31,32Chest wall pain syndrome can occur after each IGTA modality due to traumatic or ablation-related injury of the intercostal nerves, nerves of the pleural lining, myofascial tissue, or ribs (Table 1). 6Chest wall pain is associated with proximity of the ablation zone to the chest wall. 33In a single-center study, Alexander et al. 6 reported a 13.5% incidence of rib fractures in close proximity to ablation zones among 195 lung tumors treated with RFA and MWA.Chest wall pain is less common with cryoablation versus other forms of IGTA. 346][37] This is hypothesized to occur due to better preservation of the perineurium and epineurium following cryoablation, which facilitates nerve regeneration. 34

Evaluating Chest Wall Pain
Chest wall pain following local therapy for lung cancer has a broad differential diagnosis, which includes acute coronary syndromes, pulmonary embolism, tumor progression, pneumonia, abscess, and traumatic rib fracture in addition to treatment-related chest wall pain syndrome.As such, the management of patients with chest wall pain following lung cancer local therapies requires obtaining a detailed history, physical exam, labs, and imaging.Imaging should include a chest CT but can also include magnetic resonance imaging of the chest, which can identify signs of chest wall injury. 38

Management of Chest Wall Pain Syndrome
Chest wall pain occurring immediately after lung resection or IGTA is readily attributable to the procedure and is frequently managed by the treating team.However, chest wall pain developing weeks to months after surgery, CFRT, SBRT, or IGTA may present to clinicians in a primary care, emergency medicine, or other specialty setting.Often, palliation of treatment-related chest wall pain syndromes can be managed by most physicians regardless of the type of local therapy utilized for a patient's lung cancer treatment (Table 2).As will be detailed, clinicians can begin with a step-wise approach that starts with nonopioid oral analgesics (non-steroidal anti-inflammatory drugs [NSAIDs] and acetaminophen), with escalation to other drug classes as indicated. 39If a patient's pain fails to respond to this approach, clinicians can consider a referral to a pain management specialist who can tailor a more specific pharmacologic approach or perform a procedural intervention.In patients who have suspected myofascial pain, an early referral to physical therapy or integrative medicine can be considered.

Non-Opioid Oral Analgesics
NSAIDs inhibit COX-1 and COX-2 enzymes to address the inflammatory component of chest wall pain. 40Acetaminophen reduces pain via positive effects on the serotonergic descending inhibitory pathways in addition to the opioid, eicosanoid, and nitric oxide-containing pathways. 41An analysis of three randomized controlled trials (RCTs) involving 1647 participants demonstrated that the combination of acetaminophen and NSAIDs offers superior analgesia compared to NSAIDs alone. 42It is important to recognize long-term NSAID use is associated with gastrointestinal ulcers, dyspepsia, acute or chronic kidney disease, and increased cardiovascular events. 43While acetaminophen is associated with fewer adverse effects, hepatoxicity can occur when daily doses exceed 4000 mg. 44When the combination of NSAIDs and acetaminophen does not address all pathophysiological components of chest wall pain, intensification of medical therapy may be required.

Oral Glucocorticoids
Oral glucocorticoids such as dexamethasone, prednisone, and methylprednisolone also play a role in treating chest wall pain syndrome. 45They address inflammatory pain by reducing prostaglandin synthesis, vascular permeability, and tissue edema; they address neuropathic pain by reducing spontaneous discharges from injured neurons, and they improve osseous pain. 45,46owever, glucocorticoids are associated with increased appetite and weight gain, proximal muscle weakness, insomnia, gastrointestinal ulcers, psychiatric disturbances, and reduced bone mineralization. 45,46Glucocorticoids are also associated with an increased risk of

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Management of Chest Wall Pain infections, especially in patients who have recently received chemotherapy and may be immunosuppressed. 47Glucocorticoids are generally given at the lowest effective dose and limited to only a few weeks.Glucocorticoids should be avoided in patients who are still healing from recent surgery and are advised to be administered with proton pump inhibitors or sulfamethoxazole and trimethoprim prophylaxis as clinically appropriate.Physicians who practice in areas with high incidence of M. tuberculosis should consider screening patients for tuberculosis prior to initiating glucocorticoids.

Anticonvulsants
Gabapentin is an anticonvulsant drug that can be considered for patients with neuropathic pain refractory to non-opioid oral analgesics. 48Gabapentin reduces pain by inhibiting the upregulation of a2d-1 subunits that occurs following nerve injury to the dorsal horn neurons. 49Sihoe et al. 50used gabapentin to treat 45 patients with persistent chest wall pain following thoracic surgery or trauma.Patients were titrated up to 300 mg three times daily, leading to 73% of patients reporting an improvement in pain with 42% reporting greater than 50% reduction in 10-point pain score.Stephans et al. 39 examined 9 patients with SBRTrelated pain treated with gabapentin, demonstrating that it helped some of the more severe cases of toxicity.Gabapentin is well-tolerated with less than 4% of patients discontinuing treatment due to an adverse effect. 51However, adverse effects can occur and include symptoms of dizziness, somnolence, ataxia, and confusion.Adverse effects are more likely to occur at high doses (1800 mg/day) or in patients with severe renal impairment. 49ther anticonvulsants that have been studied for neuropathic pain include pregabalin, topiramate, zonisamide, carbamazepine, and oxcarbazepine.Of these, pregabalin has the best evidence supporting its efficacy. 51Among patients who received chemoradiation for lung cancer and developed neuropathic chest wall pain, pregabalin (150 mg twice daily for 3 mo) was shown to significantly improve Leeds Assessment of Neuropathic Symptoms and Signs (7-item pain scale out of 24 total points) and visual analogue scale (visual marking by patients on a 10-cm line to represent severity of pain from 0 to 10 cm) scores at one month and three months (p < 0.001 for all).Only two out of 22 patients discontinued treatment due to drug-related adverse effects. 52Other anticonvulsants lack strong evidence to support their use in pain management and had significantly higher rates of adverse effects like dizziness, drowsiness, or confusion compared to gabapentin and pregabalin. 51

Serotonin and Norepinephrine Reuptake Inhibitors
Serotonin and norepinephrine reuptake inhibitors (SNRIs) can also be considered for neuropathic chest wall pain refractory to non-opioid oral analgesic medication.SNRIs include duloxetine, venlafaxine, and desvenlafaxine.They block reuptake of both serotonin and norepinephrine, resulting in increased neurotransmitter concentrations in the synaptic cleft.Several metaanalyses have shown that duloxetine and venlafaxine significantly reduce neuropathic pain levels compared to placebo without significant toxicity rates. 51,53,54Among 22 patients who received chemoradiation for lung cancer and developed neuropathic chest wall pain, duloxetine (60 mg daily) was shown to significantly improve Leeds Assessment of Neuropathic Symptoms and Signs and visual analogue scale scores at one month and three months (p < 0.001 for all). 52No patients had to discontinue treatment due to drug-related adverse effects.Adverse effects can occur with SNRIs and include nausea, xerostomia, and weight gain. 51

Tricyclic Antidepressants
Tricyclic antidepressants (TCAs) are a less commonly used oral medication class that can be considered for neuropathic chest wall pain refractory to non-opioid oral analgesic medications, which include amitriptyline, nortriptyline, clomipramine, desipramine, and doxepin.They block reuptake of serotonin and norepinephrine, while also serving as competitive antagonists to alpha cholinergic, muscarinic, and histaminergic receptors.Amitriptyline is the most studied TCA for treating neuropathic pain. 51Unfortunately, there are no specific trials that used TCAs to treat chest wall pain syndrome.The most robust evidence available is a meta-analysis of patients with neuropathic pain, which included postsurgical and cancer-related pain.According to the meta-analysis, among the 18 RCTs that studied TCAs for neuropathic pain, rates of patients reporting a reduction of 50% or more in their pain levels were 28% higher in the TCA arms compared to the placebo arms.Most of these trials used amitriptyline in the TCA arm.Reported adverse effects included urinary retention, xerostomia, cardiac conduction abnormalities, and confusion. 51

Topical Medications
In addition to oral medications, there are topical medications that can treat neuropathic pain with fewer adverse effects.These can include ketamine, anesthetics (lidocaine), muscle relaxants (baclofen or cyclobenzaprine), and NSAIDs (ketoprofen or diclofenac).Ketamine acts as an NMDA receptor antagonist, GABA A receptor agonist, and opioid receptor re-sensitizer.It has been shown to help with neuropathic pain both centrally and peripherally.When applied topically, it offers significant pain relief without significant systemic absorption or clinically reported side effects. 55Lidocaine inhibits voltage-gated sodium channels, temporarily blocking nerve signaling.A systematic review of neuropathic pain treatments by Wolff et al. 56 found that topical lidocaine was comparable in efficacy to oral medications like amitriptyline, pregabalin, and gabapentin but with fewer adverse effects.A systematic review by Maloney et al. 57 similarly found that topical lidocaine can be highly effective for neuropathic pain syndromes while maintaining an excellent safety profile.Topical NSAIDs can also provide analgesia with lower systemic side effects than oral NSAIDs, including lower rates of cardiovascular events and less of an effect on platelet function. 57However, topical NSAIDs have not been well-studied with RCTs in the setting of neuropathic pain.

Opioid Analgesics
In cases of severe chest wall pain refractory to other treatment modalities, especially when a symptomatic rib fracture has been identified, opioid analgesics may offer short-term relief.Opioids activate opioid receptors in the central nervous system to block pain signals and increase dopamine levels.Examples of common opioids prescribed in the outpatient setting include tramadol, hydrocodone, oxycodone, and morphine.While opioids can be highly effective for managing acute pain, such as in the case of a rib fracture, they have more limited efficacy for neuropathic pain compared to placebo (response rate of 47% versus 30%). 58Opioid use is associated with several adverse effects, including constipation, drowsiness, nausea, and dizziness and can cause fatal overdoses. 58There is also a significant risk of developing tolerance and dependence to opioids from long-term use. 59,60Therefore, opioids should be carefully managed and administered in conjunction with nonopioid interventions. 60

Pentoxifylline and Vitamin E
In cases of chest wall pain following CFRT or SBRT, trials of pentoxifylline and vitamin E have been reported to help normal tissue recovery from late effects of radiation therapy.This is best reported in cases of osteoradionecrosis of the ribs. 61Pentoxifylline works as a non-selective phosphodiesterase inhibitor and decreases blood viscosity by increasing red blood cell flexibility.This improves blood flow and oxygenation in irradiated, fibrotic tissue.Vitamin E is an antioxidant that protects cells against free radicals, including those produced from radiation therapy.Vitamin E has anti-inflammatory and anti-fibrotic effects. 62Both medications can cause mild gastrointestinal side effects and should be avoided in combination with medications like warfarin due to an increased risk of bleeding.

Physical Medical Techniques
Physical medicine techniques can be considered as alternatives or adjuncts to analgesic medication in all patients with chest wall pain who do not experience satisfactory relief from pharmacologic management, especially when myofascial pain is suspected.These techniques include acupuncture, trigger point injections, deep massage therapy, and intercostal release exercises.

Acupuncture
Acupuncture entails inserting small needles into specific acupuncture points to provide pain relief to patients by enhancing endogenous opiates. 63According to a meta-analysis of 39 RCTs studying acupuncture in the setting of osteoarthritis, shoulder pain, or nonspecific musculoskeletal pain, acupuncture offered superior pain relief compared to sham acupuncture and no acupuncture (p < 0.001 for both). 64The benefits of acupuncture persisted over time with only a 15% decrease in efficacy after one year of consistent use.Another study by Roshanzamir et al. 65 enrolled 30 patients shortly after undergoing open-heart surgery.Patients were randomized 1:1 between receiving and not receiving acupuncture to their bilateral acupoints in addition to standardof-care exercise therapy and routine analgesia.They found that patients randomized to acupuncture had higher rates of improvement in their pain scores (p < 0.001) and lower analgesic use (p < 0.001).

Trigger Point Injections
An alternative approach to treat myofascial pain is trigger point injections.Providers trained in this technique identify myofascial trigger points where patients have localized tenderness and a referred pain pattern and inject them with either local anesthetics (lidocaine, bupivacaine, or prilocaine), a mixture of local anesthetic and glucocorticoids (e.g., lidocaine with triamcinolone acetonide), botulinum toxin type A, or normal saline. 66he literature remains inconsistent regarding which injection solution is most effective. 66An RCT of 28 patients with myofascial pain randomized patients to injections with normal saline versus lidocaine with triamcinolone acetonide. 67They found that patients in both arms had a three-point improvement in their pain levels on a 10point scale after two weeks, and that there was no significant difference between these two interventions.Many clinicians are therefore favoring the use of normal saline due to the reduced risk of hypersensitivity reactions, drug allergies, or local anesthetic toxicity.

Deep Tissue Massage Therapy
A less invasive therapy to address myofascial chest wall pain is deep tissue massage therapy with muscle stripping. 68This technique is performed by physical therapists to cause reflexive hyperemia and improve muscle fascia flexibility.A retrospective review by Hsu et al. 68 found that muscle stripping in patients following thoracoscopic surgery led to significantly lower pain scores, shorter hospitalization duration, and reduced need for additional analgesics compared to conventional analgesia alone (p < 0.001 for all).

Intercostal Myofascial Release Exercises
An alternative technique used by physical therapists to treat myofascial pain is performing intercostal myofascial release exercises."Bucket handle release" and "surfing the ribs" techniques are used on the intercostal muscles to relieve myofascial tension and improve patient comfort with respiration.This has not been specifically studied for chest wall pain syndrome.However, a meta-analysis of myofascial release exercises for conditions like fibromyalgia, cervical spine pain, and lumbar spine pain found encouraging results among nine RCTs.They showed that myofascial release exercises had superior pain relief compared to sham treatment or no treatment. 69

Intercostal Nerve Block and Nerve Ablation
For patients with severe chest wall pain that is refractory to medical management, a referral to a pain specialist can be considered for intercostal nerve blocks, which can temporarily relieve symptoms.In this approach, palpation or image-guidance (fluoroscopy, ultrasound, or CT) are used to directly inject intercostal nerves with approximately 2 mL of 0.25% to 0.5% bupivacaine per intercostal nerve using 23-to 25-gauge needles. 70,71Glucocorticoids can be used in conjunction with local anesthetic. 72Intercostal nerve block are used to both confirm the site and source of the pain and to provide pain relief.If the duration of pain relief is satisfactory, repeat temporary nerve blocks can be performed before nerve ablation, or neurolysis, is undertaken.Often, a prolonged anesthetic effect occurs with partial or complete alleviation of pain.
For longer-lasting effect, intercostal nerve ablation can be performed under CT or ultrasound-guidance using RFA or cryoablation as a form of semi-permanent blockade.In RFA, medium-frequency alternating current is used to induce coagulation necrosis and nerve cell death. 71In cryoablation, a cryoprobe is used to freeze the target and disrupt axonal continuity between the sensory nerve endings and the central nervous system. 34n both cases, local anesthetic is injected before proceeding with ablation. 73The target is the nerve ramus that forms the intercostal nerve approximately 1 cm lateral to the intervertebral foramina.These interventions are most effective in patients who have pain localized to a few dermatome levels, such as in cases of pain related to a surgical incision or ablation site.
Both RFA and cryoablation have promising data.In a case series of two patients with post-surgical intercostal neuralgias, RFA led to a significant improvement in patients' pain with no procedural complications. 74In a retrospective series of 18 patients who underwent cryoablation for post-thoracotomy pain syndrome, the authors reported a mean improvement in pain scores of 3.4 points on a 10-point scale following the procedure. 75No procedural complications were reported.Cryoablation does not typically have a permanent effect on nerves since the perineurium and epineurium are very fibrous tissues and can resist damage from freezing. 34Therefore, over the subsequent weeks to months, the perineurium and epineurium can facilitate regrowth of the nerve and pain re-emergence, requiring retreatment.In one study of 13 patients with post-thoracotomy pain who were treated with cryoablation, two patients experienced pain re-emergence that required retreatment at 6 and 10 months. 4In contrast, RFA causes more permanent destruction of myelinated fibers.Nonetheless, a similar nerve regeneration phenomenon has been reported with RFA where macrophage migration and Schwann cell proliferation can lead to axonal sprouting and nerve regeneration. 72Overall, cryoablation is the preferred modality for intercostal nerve ablation.

Conclusion
Chest wall pain after surgical and non-surgical therapies for lung cancer has overlapping etiologies and management strategies.The underlying pathophysiology of the pain is multifactorial in nature and involves inflammatory, neuropathic, myofascial, and osseous components.In most instances, the duration of pain is selflimited.For patients with persistent or debilitating chest wall pain syndromes, management strategies can include analgesic medications, topical treatments, physical medicine techniques, and intercostal nerve block and ablation.Fortunately, palliation of treatment-related chest wall pain syndromes can be managed by most clinical providers, regardless of the type of local therapy utilized for a patient's lung cancer treatment.When medical management fails, referring to pain specialists is recommended.

Table 1 .
Causes of Chest Wall Pain Syndrome NeuropathicIntercostal or pleural nerve injury from probe placement or from overlap between the nerves and the ablation zone.Cryoablation Myofascial Myofascial tissue disruption or injury from probe placement or from overlap between the chest wall and the ablation zone.OsseousRib fracture following ablation from overlap between the ribs and the ablation zone.